tbuckley/cabot-search huggingface dataset:
DS08 (P26) Risk factors for complications in cutaneous squamous cell carcinoma and proposal of a simplified follow-up strategy: making use of available healthcare resources
Authors: Daniel Micallef, Alicia Dimech, David Pisani, Liberato Camilleri, Lawrence Scerri
Journal: British Journal of Dermatology (2023)

Abstract Cutaneous squamous cell carcinoma (cSCC) is a common malignancy, generally cured by surgical excision. A minority of such tumours recur, metastasize or even cause death. The 2021 British Association of Dermatologists (BAD) guidelines outline high-risk features that are used to guide the follow-up of patients after a primary cSCC. The aims of this study were to identify histological features of cSCC that are significantly associated with the development of complications and to compare the sensitivity, specificity and number of appointments required to follow-up patients using different follow-up criteria. In total, 556 cases of primary invasive cSCCs excised between January 2014 and March 2018 were included and followed-up for a minimum of 4 years. Five per cent (n = 26) of tumours were associated with at least one cSCC-related complication, namely, local recurrence 3.8% (n = 21), nodal metastasis 1.6% (n = 9), distant metastasis 0.4% (n = 2) and disease-specific death 0.7% (n = 4). The initial diagnosed complication was local recurrence in 20 of 26 cases. Only two patients had the first complication beyond 2 years of the original cSCC. Factors that were statistically significantly associated with the development of a complication (P &amp;lt; 0.001) were larger diameter, larger depth of invasion, tumour invasion beyond the dermis, perineural invasion (irrespective of size), lymphovascular invasion, gross bone erosion and deep margin &amp;lt; 1 mm. Differentiation and peripheral margin were not significantly associated with complications. Therefore, it may be proposed that patients with tumours with at least one of the following risk factors be followed-up: diameter &amp;gt; 40 mm, depth of invasion &amp;gt; 6 mm, invasion beyond the dermis, presence of perineural or lymphovascular invasion or deep margin &amp;lt; 1 mm. In adopting these criteria, 739 appointments in 156 patients would be required over 2 years (4-monthly during the first year and 6-monthly during the second year). Twenty of the patients who developed a complication would be followed-up (sensitivity 76.9%, specificity 69.4%). Using the BAD guidelines, up to four more patients with complications would have been followed-up (sensitivity 92.3%, specificity 44.7%), but this would have required a total of 1556 follow-up visits in 242 patients. Given the limited resources, patient burden and the fact that local recurrence is most often the first complication, it may be reasonable to offer routine follow-up only to patients who have at least one of the proposed criteria. Coupled with patient education, this strategy could greatly reduce the number of follow-up visits required. Such a strategy may allow resources to be utilized to reduce waiting times, particularly for 2-week wait referrals, decreasing the delay in new skin cancer diagnoses.
PA31 Congenital alopecia areata: a systematic review
Authors: Aileen Feschuk, Maxwell Green, Manuel Valdebran
Journal: British Journal of Dermatology (2023)

Abstract Alopecia areata (AA) describes nonscarring, generally patchy, hair loss that can affect the entire scalp [alopecia totalis (AT)] and body [alopecia universalis (AU)]. AA is considered to be an acquired autoimmune condition. However, cases of congenital AA (CAA) have been reported. This study aimed to summarize and analyse data from existing CAA reports. No funding was obtained for this research. Following the PRISMA guidelines, PubMed and Web of Science were searched. Records reporting cases of AA present at birth were included. Twelve patients were identified, with a female predominance (n = 7; 58%). Three were premature (25%). Alopecic pattern at birth was AA in eight cases (67%), AT in two (17%) and AU in two (17%). A positive family history of AA was reported in five cases (42%). The AA diagnosis was clinical in eight cases (67%) and biopsy-proven in four (33%). Nine patients received/reported treatment (75%). Of those treated with topical corticosteroid (TCS) alone (n = 3/9; 33%), two demonstrated total regrowth (67%), while one experienced development into AU (33%). Two patients were treated with TCS and a topical vasodilator (TV), minoxidil (22%). One experienced full regrowth, while the other demonstrated partial regrowth, until the TCS was discontinued (i.e. the TV was used alone), and AT resulted. One patient was treated with TCS and oral antihistamine (11%), and one was treated with placebo lotion (11%). Both experienced partial regrowth. Two patients were treated with oral pulse steroid, a topical immunomodulator and TV, but no follow-up was provided (22%). Limitations of this review include small sample sizes and the possibility of missed cases due to a lack of well-established terminology and under-reporting. Additionally, not all cases were biopsy-proven. Biopsy is not necessary for AA diagnosis but is helpful in confirming unique (e.g. congenital) presentations of the condition. Given that AA is typically considered an acquired autoimmune condition, congenital cases call our understanding of AA into question. However, a positive family history in five cases suggests that genetic factors are involved in the development of CAA, as with acquired AA. Additionally, the female predominance of CAA is in keeping with acquired AA. Finally, given that TCSs yielded partial or total hair regrowth in five of six patients who received them (83%), TCSs are a reasonable first-line treatment option for CAA. In conclusion, CAA should be considered as a differential diagnosis of alopecia in the newborn, and increased CAA awareness should result in an increased number of patients receiving proper treatment.
P30 Declining staff numbers and increasing workload: is there a solution?
Authors: Charlotte Wolfe, Rebecca Phillips, Dhruvkumar Laheru, Rachel Fisher
Journal: British Journal of Dermatology (2023)

Abstract Within the UK, there is a rapidly rising incidence of malignancies, including cutaneous cancers. Over 1 million new patients are referred to dermatology each year and a large proportion require a diagnostic or therapeutic biopsy. Dermatologists often rely on histopathology to confirm or diagnose cancers, determine margins and perform specialist testing. The increasing rates of cancers are adding significantly to the histopathology workload. According to the Royal College of Pathologists (RCPath), only 3% of departments report having adequate staff to meet clinical demand. There are a significant number of unfilled training posts and a concurrent retirement crisis, with 25% of all pathologists over 55 years old. It can take up to 15 years to train consultants, with the more experienced able to handle greater workloads. The lack of pathologists, with widespread vacancies, has a significant impact. The resulting costs to the health service of employing locums and outsourcing work have been estimated to be £27 million annually. For patients, the costs of these shortages mean delays in diagnosis and treatment. A RCPath key performance indicator advises that 80% of cases should be reported within 7–10 calendar days. Across dermatology departments, there is wide reported variation in reporting times from 1 to 28 weeks. In 2019, the longest wait, on average, was 5.8 weeks. We surveyed 60 histopathology consultants across different National Health Service trusts in England to determine the reasons behind these delays. The survey response rate was 45%. The results showed that 78% of departments have unfilled posts, 83% have employed locum staff or outsourced reporting of skin biopsies in the last 5 years and only 20% are able to meet the RCPath guidance. Additionally, almost one-quarter reported that they have had complaints or serious incidences related to delayed dermatopathology reporting. Survey comments revealed many other areas of potential diagnostic delay from sample labelling and prioritizing to prolonged laboratory processing times, unclear pathways to expedite samples and the lack of histopathology secretaries. This survey highlights the increasing workforce demands and emphasizes the need for innovative changes to avoid delays in patient care. Possible solutions to address increased workload in an understaffed environment include adequate secretarial support, increasing pathology pathway navigators who prioritize urgent cases, improving information technology services, digital slide reporting and developing artificial intelligence to screen samples. Increasing dermatopathology training and exposure to histopathology at a junior level is mandatory. Raising these issues and making them a key investment priority for the government is imperative.
P52 Addressing the overtreatment of basal cell carcinoma and other skin cancer in the UK
Authors: Ahmad Elmansouri, Jessica Alcena, Zoë Venables, Birgitta van Bodegraven, James Powell, Paul Gazzani
Journal: British Journal of Dermatology (2023)

Abstract The incidence of keratinocyte cancers continues to increase in the UK, although survival is favourable compared with other cancers. This, coupled with a progressively ageing population, has resulted in an increasing number of clinical situations in which we question the benefit to the patient of treating their skin cancer. Currently, the main barrier to preventing overtreatment is the lack of a nationally accepted method for determining survival in patients with skin cancers. This study aims to identify trends in national datasets that support decision-making in basal cell carcinoma (BCC) intervention for frail patients. Frailty is multifactorial, but age is an independent predictor of physical frailty. National databases (Get Data Out—CancerData; national life tables from the UK Office for National Statistics) were accessed to identify the average life expectancy at a given age based on the mortality rates experienced between 2018 and 2022. Average life expectancy reduced in a linear fashion with increasing age. At 80 years of age, the average number of years a woman survived was 9.66 years vs. 3.6 years at 93 years of age. Crude rates for BCC in the whole population (total BCC) are lower than the crude rates in the older population (80+ years). Kaplan–Meier survival (i.e. how many patients are alive after 5 years) was 80% overall and dropped to approximately 55% for the population aged 80+ years. These data support the notion that with increasing age and subsequent frailty, life expectancy in the general population independent of comorbidities shortens. Having hard cutoffs for surgical intervention by age is a reductionist approach. Potential decision aids include frailty scores. Some frailty scores are specifically designed to estimate all-cause mortality. The OPERAM (Optimising Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older People) trial compared several of these mortality scores. The Gagné Index performed most highly with a positive predictive value of 31% and a negative predictive value of 85% (Schneider C, Aubert CE, del Giovane C et al. Comparison of 6 mortality risk scores for prediction of 1-year mortality risk in older adults with multimorbidity. JAMA Netw Open 2022; 5:e2223911). The combination of national data and predictive scoring systems may be helpful in supporting decision-making when considering surgical intervention. Modification of this approach to achieve greater predictive value may be possible in order to achieve better outcomes.
009 Comparing the number needed to biopsy (NNB) ratio for melanoma diagnosis between teledermatology and face-to-face models of care
Authors: Khawar Hussain, Nada Khalil, Amir Amini, Neil Patel
Journal: British Journal of Dermatology (2023)

Abstract The Elective Recovery Plan, published by NHS England (2022), has advocated that teledermatology (TD) should be available in every service receiving urgent suspected skin cancer referrals. However, evidence supporting the effectiveness of TD for the accurate diagnosis and triage of skin lesions remains limited. A 2018 Cochrane review found variable agreement between TD and face-to-face (FTF) assessment of lesions considered to be of low concern when seen FTF, with remote assessment more likely to recommend intervention (including excision) for low-risk lesions. The number needed to biopsy (NNB) ratio, calculated by dividing the total number of biopsies by the number of biopsied skin cancers, is increasingly used as a metric for the diagnostic accuracy for melanoma detection, with a low ratio suggesting high specificity and vice versa. We undertook a study to compare the NNB ratio for melanoma detection between TD and FTF models for assessing new 2-week-wait (2WW) skin cancer referrals within our service. Over 2019–2020, the service switched over from FTF to a full TD consultant-run model for 2WW referrals. Retrospective analysis of the FTF 2WW model between August and November 2018 identified 53 cases suspicious for melanoma referred for biopsy [30 women and 23 men; median age 44 years (range 27–90)]. Of these, six patients received a histopathological diagnosis of melanoma (NNB 8.8). Retrospective analysis of the TD model between August and November 2022 identified 62 cases suspicious for melanoma triaged directly to a biopsy appointment [37 women and 25 men; median age 49.5 years (range 18–90)]. Of these, three patients received a histopathological diagnosis of melanoma (NNB 20.7). NNB in the TD model was 2.3 times higher than in the FTF model. The NNB of 8.8 in our FTF 2WW model is comparable to a review of 46 studies, which generated an NNB of 7.5 for dermatologists worldwide. The higher NNB of 20.7 for TD indicates poorer diagnostic accuracy for melanoma in this model. The higher NNB in TD is consistent with previous findings that remote assessment is more likely to lead to the excision of low-risk lesions. Further large-scale studies are needed to compare NNB in teledermatology vs. FTF models of skin cancer assessment. TD brings considerable advantages of convenience and increased clinic capacity but may come at a cost of lower specificity for melanoma diagnosis and an increase in the number of biopsies of benign lesions.
BC02 Efficacy and safety of picosecond Nd-YAG laser for tattoo removal in Asian patients: a way to look forward
Authors: Rohit Bansal, Priyadarshini Sahu
Journal: British Journal of Dermatology (2023)

Abstract Picosecond neodymium-doped yttrium aluminium garnet (Nd-YAG) lasers have emerged as the leading technology for tattoo removal due to their shorter pulse lengths and are considered better than other nanosecond lasers. The aim was to study the efficacy and adverse effects of a picosecond quality-switched (QS) Nd-YAG laser in a case series of 15 Asian patients for tattoo removal. Fifteen patients with black- and blue-coloured tattoos were recruited for tattoo removal. All were treated with a 1064-picosecond QS Nd-YAG laser. A single session with one pass was performed using a spot size of 4 mm, a fluence of 0.5–1 J cm–2 and a frequency of 6–10 Hz. The parameters were adjusted based on the size and type of tattoo and the patient’s skin type. Patients were treated at 4–6-weekly intervals. The clearance of pigmentation and local reactions was evaluated based on clinical photographs and dermoscopy, done at each sitting. At the end, both patients and physician assessed the clearance of tattoo. For patient assessment, a visual analogue scale (VAS) was used. To assess the efficacy of laser treatment by the physician, the tattoo removal rate was scored on a 5-point (0–4) scale (4: ≥ 70% removal, excellent improvement; 3: ≥ 50% and &amp;lt; 70%, marked improvement; 2: ≥ 30% and &amp;lt; 50%, moderate improvement; 1: ≥ 10% and &amp;lt; 30%, mild improvement and 0: &amp;lt; 10%, no effect). Patients were asked to assess their satisfaction (0 = dissatisfactory, 10 = satisfactory) and pain (0 = no pain, 10 = worst pain) using the VAS. Clinical photographs were assessed both by the patients and the physicians. Four women and 11 men were included (aged 30–45 years). At the end of treatment, all patients had &amp;gt; 75% clearance and seven obtained almost complete clearance. Thus, all patients had an excellent response. The average patient-reported score for satisfaction was 8.2 and 2.5 for pain. The average score was 4.4 for the number of sessions. A few adverse effects, including erythema, blistering and crusting, were observed. Picosecond lasers allow for the most effective delivery of thermal radiation to tattoo particles through more specific photothermal and photomechanical effects than traditional nanosecond lasers. They also have an additional effect of minimizing the collateral damage to the surrounding dermis and epidermis. Thus, a picosecond laser is a safe and effective method for tattoo removal in Asian people.
P32 Impact of the COVID-19 pandemic on health equality in malignant melanoma diagnosis
Authors: Kenny Lau, Huan Cheng, Rima Hussain
Journal: British Journal of Dermatology (2023)

Abstract Difficult access to care during the COVID-19 pandemic has led to a delay in some disease diagnoses. The pandemic has exacerbated pre-existing health inequalities, and the most deprived population has often been the most disproportionately affected. In this study, we investigated the impact of COVID-19 on the volume and pattern of melanoma diagnosis, to evaluate whether there is an association with the socioeconomic status of the population. Cases with newly diagnosed cutaneous melanoma from January 2019 to December 2021 were identified in a specialist multidisciplinary team-held database. Breslow thickness, pathological disease stage, patient demographics and postcodes were reviewed. In the 3-year study period, there was a total of 1910 cases. Compared with 2019 prepandemic data, there was a 31% reduction (P = 0.03) in melanoma cases diagnosed in 2020 and a 10% reduction (P = 0.09) in 2021. In 2020, stage 4 cases had a 46% increase (P = 0.031). In 2019, 7% of the most deprived population had stage 4 disease at diagnosis, which increased to 21% in 2020 (P = 0.02). COVID-19 has caused a dramatic reduction in the volume of melanoma diagnoses and an accompanying upstage of disease. Among the most deprived population in our region, they are three times more likely to receive a stage 4 diagnosis vs. before the pandemic. This suggests that the barrier to health care secondary to the pandemic is most apparent to the deprived population and probably caused a delay in cancer diagnosis among this group of patients. Health policy needs to be put in place urgently to address this health inequality, to minimize the prognostic impact on the population.
CPC09 New-onset agminated Spitz naevi following hypopigmented pityriasis lichenoides chronica
Authors: Laura Adams, Brinder Chohan, Tanya Bleiker
Journal: British Journal of Dermatology (2023)

Abstract A 9-year-old girl presented to dermatology with erythematous scaly patches affecting her legs and arms, and hypo­pigmented patches affecting the trunk. She was otherwise fit and well, with no preceding illness or new medications. Treatment with mometasone 0.1% and an emollient was unsuccessful. Two years later, she had continued to develop new hypopigmented patches, as well as dark clustered naevi on the trunk. An incisional biopsy was taken from a hypopigmented patch of the right abdomen and one of the new naevi from the right hip. Incisional biopsy of the hypo­pigmented patch showed scattered necrotic keratinocytes in the epidermis with mild hydropic degeneration of basal cells and a mild superficial and perivascular lymphohistiocytic infiltrate in the dermis, consistent with pityriasis lichenoides chronica (PLC). Incisional biopsy of an eruptive naevus showed a junctional proliferation of melanocytes with overlying epidermal hyperplasia and hyperkeratosis and transepidermal elimination of melanin. Nests of epithelioid melanocytes were present at the rete tips, with no pagetoid spread and no atypia, consistent with an eruptive Spitz naevus. PLC is a benign lymphoproliferative disorder, typically presenting with erythematous scaly papules that relapse and remit. However, cases of PLC presenting with hypopigmentation alone have also been reported, as in this case, which can be part of a postinflammatory dyspigmentation or active disease (Elbendary A, Abdel-Halim MR, Youssef R et al. Hypopigmented lesions in pityriasis lichenoides chronica patients: are they only post-inflammatory hypopigmentation? Aust J Dermatol 2021; 63:68–73). The clustered pattern of Spitz naevi in this patient is termed agminated Spitz naevus. Eruptive disseminated and agminated Spitz naevi are much rarer than the solitary presentation. Triggers of eruptive Spitz naevi include pregnancy, blistering disorders and topical tacrolimus, and in one case following pityriasis lichenoides et varioliformis acuta (Mazzurco J, Menssen K, Schapiro B et al. Eruptive disseminated Spitz nevi in a 26-year-old African-American woman. Int J Dermatol 2012; 51:1270–1), while agminated Spitz naevi are reported to occur after radiotherapy and sunburn, and to arise in naevus spilus or congenitally hypo- or hyperpigmented patches. No cases of malignancy in agminated or eruptive disseminated Spitz naevi have been reported. In this case, the new onset of agminated Spitz naevi may have been triggered by the inflammatory process of PLC. As far as we can ascertain, there have not been previous cases of this published in the literature. Our patient’s hypopigmented areas have now started to self-resolve and we have planned for ongoing monitoring of the agminated Spitz naevi.